Diagnosis of penile cancer

Diagnosis is the process of finding out the cause of a health problem. Diagnosing penile cancer usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and may do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for penile cancer or other health problems.

The process of diagnosis may seem long and frustrating. It’s normal to worry, but try to remember that other health conditions can cause similar symptoms as penile cancer. It’s important for the healthcare team to rule out other reasons for a health problem before making a diagnosis of penile cancer.

The following tests are usually used to rule out or diagnose penile cancer. Many of the same tests used to diagnose cancer are used to find out the stage (how far the cancer has spread). Your doctor may also order other tests to check your general health and to help plan your treatment.

Health history and physical exam

Your health history is a record of your symptoms, risk factors and all the medical events and problems you have had in the past. Your doctor will ask questions about your history of:

symptoms that suggest penile cancer

human papillomavirus (HPV) infection

foreskin that does not fully pull back (retract) (called phimosis)

poor genital hygiene

not being circumcised

weakened immune system

smoking

treatment for psoriasis

A physical exam allows your doctor to look for any signs of penile cancer. During a physical exam, your doctor may:

Blood chemistry tests

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are functioning and can help find abnormalities. Blood chemistry tests used to diagnose penile cancer include the following.

Serum calcium measures the calcium levels in the blood. High levels of serum calcium (called hypercalcemia) may occur in advanced penile cancer where it has spread to the bone.

Biopsy

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. A report from the pathologist will show whether or not cancer cells are found in the sample. Circumcision (removal of the foreskin) may be done if the abnormal area is on the foreskin or if removal of the foreskin is needed to do the biopsy of the abnormal area underneath.

Excisional biopsy involves removing the entire abnormal area. This type of biopsy may be used if the lesion or abnormal area is small. If the abnormal area is only on the foreskin, circumcision may be done. If the abnormal area is small or confined to the foreskin, it can often be completely removed by an excisional biopsy.

Incisional biopsy involves removing only a small piece of tissue from the abnormal area. This type of biopsy may be used if the lesion or abnormal area is large, seems to be growing deeply into the tissue or is ulcerated (appears as an open sore on the skin).

Lymph node biopsy

The most common place for penile cancer to spread is the lymph nodes in the groin that are closest to the penis. A lymph node biopsy removes lymph nodes or cells from lymph nodes during surgery so they can be examined under a microscope to find out if they contain cancer.

The doctor will examine the lymph nodes to check if they look or feel swollen. If the lymph nodes cannot be felt they are called clinically uninvolved lymph nodes. If the lymph nodes are large and firm to the touch they are called clinically involved lymph nodes.

If the lymph nodes cannot be felt, the doctor may monitor the lymph nodes using imaging tests (CT, MRI or PET scan) or may do a sentinel lymph node biopsy (SLNB).

If the lymph nodes are large and firm to the touch, the doctor will do a fine needle aspiration (FNA) biopsy to check for cancer.

In some cases, the lymph nodes are not checked with an SLNB or FNA but instead surgery may be used to remove a few lymph nodes from an area (called lymph node sampling).

Fine needle aspiration (FNA) may be used to remove some fluid from an enlarged lymph node to check for cancer cells. An FNA is sometimes used instead of removing lymph nodes to see if they contain cancer. If the biopsy shows that there are cancer cells present, surgery may be done to remove all the lymph nodes in the area. The doctor may use an ultrasound or a CT scan to guide the needle into the lymph node if it is too deep to be felt.

If the results of an FNA are negative (cancer cells are not present), the biopsy may be repeated and the doctor may monitor the lymph nodes using imaging tests.

If the results of an FNA are positive (cancer cells are present), all of the lymph nodes in the area may be removed.

Sentinel lymph node biopsy (SLNB) may be used to assess whether lymph nodes are involved and if removing lymph nodes is necessary. The sentinel node is the first lymph node or cluster of lymph nodes that receives fluid from the area around a tumour. Cancer cells will most likely spread to these lymph nodes first. An SLNB is the removal of the sentinel lymph node so it can be examined to see if it contains cancer cells. There may be more than one sentinel lymph node, depending on the drainage route of the lymph vessels around the tumour.

If the results of the SLNB are negative (cancer cells are not present), it is unlikely that other lymph nodes are affected and no additional surgery is necessary.

If the results of the SLNB are positive (cancer cells are present), all of the lymph nodes in the area may be removed.

CT scan

A computed tomography (CT) scan uses special x-ray equipment to make 3-D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

A CT scan of the pelvis is used to see if the cancer has spread to surrounding lymph nodes, especially in men who are obese. It can also be used to see if the cancer has spread to the liver, the lungs or other organs.

Sometimes a contrast medium is used with a CT scan to help provide better detail. It is usually injected into a vein in the hand or arm.

An MRI is used to find out the size of the tumour and where the cancer is in the body. It is also used to see if the cancer has spread to surrounding lymph nodes, nearby organs and tissues or to the brain or spinal cord.

Sometimes a drug is injected into the penis to make it erect during the test. The doctor can see the inside of the penis more clearly when it is erect. Sometimes a contrast medium, such as gadolinium, is used with an MRI to help provide better detail. It is usually injected into a vein in the hand or arm.

Ultrasound

An ultrasound uses high-frequency sound waves to make images of parts of the body. It is used to find out the extent of the penile cancer. An ultrasound of the pelvis can be used to see if the cancer has spread to nearby lymph nodes, organs or tissues.

Sometimes a drug is injected into the penis to make it erect during the test. The doctor can see the inside of the penis more clearly when it is erect.

X-ray

Bone scan

A bone scan uses bone-seeking radioactive materials called radiopharmaceuticals and a computer to create a picture of the bones. It is used to see if penile cancer has spread (metastasized) to the bones.

PET scan

A positron emission tomography (PET) scan uses radioactive materials called radiopharmaceuticals to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3-D colour images of the area being scanned.

A PET scan is used to see if cancer has spread to nearby lymph nodes. It may be combined with a CT scan (called a PET-CT scan).